Request For Prehearing Conference CC-Form-13 - Oklahoma

CC-FORM-13 Send original to or er Co en a on Co i ion and 1 o to All Ot er ar e o Re ord THIS SPACE FOR COMMISSION USE ONLY WORKERS COMPENSATION COMMISSION 1915 NORTH STILES AVENUE OKLAHOMA CITY, OKLAHOMA 73105 ( lea e t e or rint) In re claim of: Full Na e o Clai ant (Injured E lo ee) Clai ant So ial Se urit Nu ber (LAST 4 DIGITS ONLY) XXX-XX-_________________________ REQUEST FOR PREHEARING CONFERENCE COMMISSION FILE NO. i ion A roved Individual Sel -In ured or Own Ri Na e o E lo er or Re ondent E lo er In uran e Carrier, er it # or Co Grou , Unin ured Date o Injur NOTE: Mediation is available to help resolve certain workers' compensation disputes. For information, call (405) 522-8760 or In-State Toll Free (800) 522-8210. 1. A re ue t i ade or t e a oned a e to be et or re earing Con eren e at t e earlie t o ible date to addre t e ollowing i ue( ): a. Mo on to Ter inate Te orar Co en a on. b. Obje on to Ter ina on o Te orar Co en a on. . Mo on to A oint an Inde endent Medi al E a iner. d. E lo er Obje on to Clai ant Re ue t or C ange o i ian. e. Mo on to Con olidate. LIST ALL COMMISSION FILE NUM ERS, EXCLUDING THE ONE LISTED A OVE. _______________ _______________ _______________ _______________ Mo on to Su end ro eeding or ene t . g. Mo on to Add Addi onal ar e . Incl e e name an com le e a re incl in e i co e of EACH a i onal ar an INSURER an e alle e DATE OF INJURY. (U e addi onal eet i ne e ar .) A CO Y OF THIS MOTION MUST E MAILED TO EACH ADDITIONAL ARTY AND INSURER LISTED. Addi ona Party Address, in ding City State i Ins rer Address, in ding City State i A eged Date of Inj ry ________________________________________ I ________________________________________ I _________________________ ________________________________________ I ________________________________________ I _________________________ ________________________________________ I ________________________________________ I _________________________ . Media on Order. (Note: Conta t t e Coun elor Divi ion dire tl to ur ue edia on b utual agree ent wit out Co i ion order.) i. Mo on to Review er anent Total Di abilit Statu ur uant to 5A O.S., 45(D). j. Ot er __________________________________________________________________________________________ ( e i ). 2. Ha an ad ini tra ve law judge reviou l been a igned b t e Co i ion to ear all a er rela ng to t e above- a oned a e? YES NO ASSIGNED ADMINISTATIVE LA JUDGE: ______________________________________________________. THE PARTY REQUESTING THIS PREHEARING CONFERENCE HEREBY CERTIFIES THAT THE PARTIES HAVE CONFERRED OR ATTEMPTED TO CONFER IN GOOD FAITH BUT HAVE REACHED AN IMPASSE AND ARE UNABLE TO RESOLVE THE ISSUE WITHOUT THE COMMISSION'S ASSISTANCE. A mini ra e Wor er ' Com en a on Ac A O.S. A 1 a : An er on or en t w o a e an aterial al e tate ent or re re enta on, w o will ull and nowingl o it or on eal an aterial in or a on, or w o e lo an devi e, e e, or ar e, or w o aid and abet an er on or t e ur o e o : (1) obtaining an bene t or a ent ... all be guilt o a elon ." An er on w o o it wor er o en a on raud, u on onvi on, all be guilt o a elon uni able b i ri on ent, a ne or bot . The undersigned declare under PENALTY OF PERJURY that they have examined all statements contained herein, and to the best of their knowledge and belief, they are true, correct and complete. Signed this ____________day of _________________, __________. H H H H H H H Signature of Re ues ng Party I HEREBY CERTIFY THAT A COPY HAS BEEN SENT TO: Opposing Party/Counsel Address Address (Number and Street) City State Zip Code City State Zip Code Telephone Number of Re ues ng Party Print or type name of A orney OA Created 2-1-14 American LegalNet, Inc. www.FormsWorkFlow.com